Images in Practice: Painful Cutaneous Vasculitis in a SARS-Cov-2 IgG-Positive Child

Abstract

Background: Cutaneous manifestation of COVID 19 in children has not yet been reviewed systematically and hence this review gives a future direction to the clinicians to be vigilant for skin presentations during such pandemic. Methodology: The review was done as per the guidelines of PRISMA and literature search was done on PubMed database using keywords as COVID-19, children and skin in different combinations. Articles published in English with cases of age 1 month to 18 years were eligible. The outcome included varied aspects of cutaneous and COVID-19 infection. The review protocol was not registered. Results: Of 51 publications identi ed, 13 studies containing 149 children met the eligibility criteria. Acrally located erythematous maculopapular lesion was the most common nding in 138 children. Erythema multiforme, varicella like exanthem and Kawasaki disease like presentations were reported in the rest of the cases. The duration of the skin lesion was 1-2 weeks in 43%. Skin biopsy done in 18 cases revealed super cial & deep perivascular and peri-eccrine lymphocytic in ltrate & lymphocytic vasculitis. RT-PCR was positive in 13.8% cases. Serological markers for HSV, parvovirus B19 analyzed across various studies, were found negative, except for mycoplasma pneumoniae in 2 of 20 cases tested. Discussion: Clinicopathologic analysis established chilblains like lesion in 43% cases with no con rmed etiology like cold exposure, autoimmune dysfunction, drug reaction, or viral infection. The usual cephalocaudal spread of a viral exanthem was also missing. However, a low number of discussed cases was a limitation of the study. Conclusion: In the absence of any con rmed etiology for such cutaneous manifestations, the possibility of COVID-19 should be explored and evaluated thoroughly during such pandemic.

Cutaneous manifestations associated with COVID-19 in children: A Systematic Review

“…Acrally located erythematous to violaceous maculopapular lesion having blurred edges, occasionally with super cial bullae and focal hemorrhagic crust was the most common nding in 127 children. [16], [20], [24], [25], [26] A similar but larger lesion as erythematous to purpuric plaques with occasional macules was reported in 11 cases. [16], [19] [21], [27] Erythema multiforme like lesion observed in 6 cases, consisted of target and targetoid, con uent macules, papules and plaques of different sizes, few with bleeding and crust at the center with the involvement of conjunctiva in one and mucous membrane in one patient each.…”

“…The varied cutaneous presentations, histopathological ndings, and other details are tabulated in table 3. Reference [16], [19], [20], [21], [24], [25], [26], [27] [17], [18], [ The majority of the children showed erythematous maculopapular eruptions, which is generally the commonest cutaneous presentation in any viral illness, however, a closer look in our study subjects throws up several contradicting observations. For instance, instead of general cephalocaudal distribution in any viral exanthem, here the cases showed involvement of acral region of feet and hands.…”

“…[11], [12] [13], [14] [15] Thus, a total of 13 articles met the inclusion criteria and were systematically reviewed. Out of that 5 were case series, [16], [17] [18], [19] [20] 4 were case reports, [21], [22] [23], [24] and 4 were original studies. [25], [26] [27], [28] Maximum number of articles were reported from Italy, [16], [19] [20], [21] [22], [24] [26] followed by Spain, [17] [23], [25] France, [8] Turkey, [28] and USA.…”

Clinical Management of Il-6 Driven Cytokine Storm Related to COVID-19 in a Patient with Recent Spinal Cord Stimulator Implants: A Case Report

“…The upregulation of the Th17/T reg equilibrium can lower immunological tolerance and trigger the mechanisms of the development of chronic inflammatory autoimmune or chronic diseases ( 6 ). The same immunological pattern is emerging caused by COVID-19 immunological damage and IL-6 overexpression ( 7 - 9 ).…”

Understanding immunopathological fallout of human coronavirus infections including COVID‐19: Will they cross the path of rheumatologists?

“…57 Pediatric patients who were positive for SARS-CoV-2 IgG also developed cutaneous vasculitis lesions. 94 In summary, ANA and aPL autoantibodies can be seen in patients with SARS and COVID-19. Theoretically, these patients may have higher chances to develop autoimmune diseases in future, like APS or a lupus spectrum disorder.…”